Impingement is a common shoulder condition that causes pain as a result of pressure on the rotator cuff from the shoulder blade. The rotator cuff is a group of muscles and tendons that stabilizes the shoulder and permits lifting and rotating movements. When impingement occurs and the arm is lifted, a bone or ligament can rub against the rotator cuff, producing pain and limiting movement. Shoulder impingement typically worsens over time.
Initially, individuals with a shoulder impingement may feel mild pain in the shoulder, which often radiates from the front of the shoulder to the side of the arm. The pain may worsen upon lifting the arm, reaching for something or throwing, and there may be some swelling and tenderness at the front of the shoulder as well. As impingement progresses, pain and stiffness worsen until the patient may not be able to lift or lower the affected arm. Eventually, if left untreated, the condition may severely limit arm motion to the point that the arm becomes difficult to move at all.
Initial treatment of shoulder impingement includes conservative measures such as resting the arm, non-steroidal anti-inflammatory medications, corticosteroid injections and a regimen of physical therapy. However, if these techniques do not provide adequate pain relief, surgery will most likely be recommended.
The Subacromial Decompression Procedure
Severe cases of impingement may require surgery to remove the pressure and create more space for the rotator cuff. The most common procedure for treating impingement is subacromial decompression. This surgery involves the removal of some of the affected tissue and part of the bursa, which is the small sac that has become inflamed due to the impingement. In some cases, the front edge of the shoulder blade must be removed as well. Either general or local anesthetic will be administered prior to the start of the procedure.
A subacromial decompression can be performed through arthroscopy or an open technique, depending on the severity of the condition. When arthroscopy is used, two to three tiny incisions are made in the shoulder area. The arthroscope and specialized surgical tools are inserted into the incisions and the surgeon uses a video monitor to view the damaged area and excise the tissue and bone as needed. Once sufficient space has been created to allow for free movement of the tendons of the rotator cuff, the surgeon will withdraw the instruments and suture the incisions closed. If the surgery is performed using an open technique, one incision is made in the shoulder, and muscles and tissues are separated to provide access to the joint and subacromial space.
Recovery from Subacromial Decompression
The length of recovery from a subacromial decompression procedure will depend on a number of factors, including whether the surgery was performed arthroscopically or through an open method. A sling may be needed after surgery to immobilize the arm and encourage initial healing. Once the sling is no longer necessary, a rehabilitation program will begin that focuses on increasing strength and range of motion in the affected shoulder. Improvements to the shoulder in comfort and function are typically apparent within a few months after the subacromial decompression procedure, but full recovery may take as long as a year.
Shoulder Instability
Shoulder instability is a condition characterized by a loose shoulder joint, caused by weakened and stretched surrounding muscles and ligaments. This may become a chronic condition after a dislocation, which occurs when the ball of the upper arm bone comes out of the socket. Chronic instability may produce frequent slipping, or partial dislocation, known as subluxation.
Shoulder instability may occur after an acute injury that stretches or tears the ligaments in the shoulder, or it may be a result of overuse. In other cases, a naturally loose joint capsule simply does not hold the ball of the humerus tightly in its socket. Athletes whose sports involve repetitive overhead motions, such as tennis and volleyball players and swimmers, have a higher instance of developing instability. The shoulder is more susceptible to this type of condition than other joints because it provides the arm with a tremendous range of motion. If a dislocation takes place, the muscles, tendons and ligaments of the shoulder may tear or loosen, resulting in the persistent slippage associated with instability.
Symptoms of Shoulder Instability
People with unstable shoulders may experience pain and limited motion in the joint and additional symptoms may include:
- Soreness
- Weakness
- Numbness in the arm
Symptoms of shoulder instability may discourage participation in sports that require stretching the arm overhead.
Diagnosis of Shoulder Instability
Shoulder instability can be diagnosed after a medical history has been taken and a physical examination performed. The exam may include certain tests of movement in order to evaluate potential shoulder instability. Additionally, imaging tests such as X-rays or MRI scans may be necessary to provide clear visualization of the bones and tissues around the shoulder.
Treatment of Shoulder Instability
Treatment for shoulder instability usually begins with conservative measures including resting the affected arm, physical therapy and use of non-steroidal anti-inflammatory medications. However, for some people these approaches may fail to provide relief. At that point, surgical treatment may be recommended. Instability surgery varies depending on the cause of the condition, but usually aims to tighten the loose ligaments of the shoulder. The two most common types of instability surgery include Bankart repair and capsular shift procedures, which may be performed in combination.
Bankart Repair – Bankart repair is used for shoulders prone to dislocation and it involves the surgeon removing torn or degenerated tissue and any bone spurs that rub on the tendons of the shoulder. The torn ligaments are then reattached to the bone with suture anchors.
Capsular Shift – Capsular shift is used to decrease and tighten the joint capsule, which is the lining of the joint, when it is too large. This is accomplished by folding the affected ligaments over on themselves and suturing them in this more layered position.
Both of these outpatient surgeries can often be performed through arthroscopy, which allows for minimally invasive procedures with smaller incisions and shorter recovery times.
Risks of Shoulder Instability Surgery
As with any type of surgery, shoulder repair surgery may pose a risk of complications. Although uncommon, risks may include:
- Bleeding
- Infection
- Blood clot
- Shoulder stiffness
- Shoulder weakness
- Nerve or blood vessel damage
In some cases, the shoulder may fail to heal after surgery.
Recovery from Shoulder Instability Surgery
Patients are required to wear a sling or another immobilization device for several weeks after surgery to correct shoulder instability in order to properly support and protect the arm. Pain medication and applications of ice may be necessary for at least a few days following the procedure. Physical therapy can be very effective in restoring the flexibility and strength to the shoulder. Recovery periods vary depending on the extent of the shoulder damage, but full recovery typically takes several months.
